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ELECTRICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNEN AUILDER DELCARAf ION
<br />I hdcby arlt'n hder I].mhy of pcrjury rhlr I am cxempl from thc Contreclos Licenss Lsw lor lhe rbllo*i,s rea$n (56.7011.5
<br />Busincss rnd Pror.ssi.n Codc) Any Cily or C.unry which rcqliEs { I.mir r. onn cr, 0l'cr. improw. d.mlish.r rctEn any
<br />(tuclurc. prior to its issuare. al$ rcqutcs lhc rt'rlton' for su.h Frmil ro lih ! si8*d {alemnl lhot h. or shc is liccnrcd ,ursanl
<br />lo rhc provhions orlh. Conlroctoas Liccnsd rjw {Chapr.r 9, CoDm.ncine wirh sc.lio.7000 ol Division I ofrhc Busincss ond
<br />Pmlt$ions Cdc) or thll hc or shc h er.m0l thcrcfrom and lhc tHsi lor rhc.lLgcd cxcn{,tion. Any viohlionofSdlion?0115 byrny
<br />onllim rn' 0pcmir {bj(.hrh. arpli,'a rn s,iuln($lryofmt mrcrh8n fivc hundreddulle\ r!500'
<br />\Ll. as owrcr .l rhc InnFny. or m, cnflnrrcs qirh wagcs 0s lhcn $t compcnsriotr. will do rhc *ork ud ttr (nx1m is nor
<br />inrc,n n or oflcrcd for sk (56 70.14, Brsitss atrd Prcfe$ions Codc The Conrraclois Licenss l,s &,e\ nol al,pl, ro d ower of
<br />rhc fmrcn, wlx) buildr or inpbvG rlrmn. alld who dds soch sik hin*lf or hcrslf o, rhhuBh hh or h.r own.mployc.s,
<br />tbvidcd rh8i strch impmtmds e [, inrcnd.n or ofrqcd tu slc. ll hov.rcr, lhc tuiktiry or iq,mrcnE n sb wnhin "nc ,Er
<br />oi s'nFkrion. thc Owmr Buildq qill hrrc lhc budcn ol prcvin8 $el tE or shc dil ml hoild or i,ig,Dvc rhc pmpsly fd rlt ll{,Inrc ot
<br />-1.
<br />asowncr ofrhc pmpcny.0m ciclusivclyconrdina *irh hc..sL'd . o trtr. ror ro.on(ruc hc fmjccl (Ss. ?04.r- Aunncs
<br />utrd PtufN\bn Cod.: Thc Cont&ror'i Li.cnsc l-trs d.cs nor lprly ro sn osn.r ofpropcny who builds or nnpiolcs docon.
<br />$d who conrEcts Io! surh rrojccrs wirh!Conrack'{s)lkcnsed pursu!trt IothcCo racrol\ Liccnr tr*)
<br />oLloL lra o**. Vav onr crr tt4-.--Jr* ^o =TOXf,EXSJOMPEUSAIIOI!
<br />DDCIASAIIA!
<br />I hcrchyatfinnundcr pcMlryotperjuryorcoilhc,bllowin8 dcchrorio.\
<br />-l
<br />hnvc sn*illnEn lin 0 Ccnificllc ofConscnt ro Sclll,suE ror workcr' cor.Dctrsrtion. as nmvilcd fo.byS(lFn 1700orlhc
<br />Llbor Codc. for lhc p.rformarcc of lhc worr for which lhc pnmir is issu.d.
<br />-l
<br />hrvcrnd *illmi'rllin workcrs conrcnsrrion insunncc. rs rcquncdhySc.ri{)n:l7O(,oilh.l]borCod.,fnrhdlfrrornur.cor
<br />rhc $r[ rr which rni\r.rn,ir ir isru.d Mysorkc.r ompco*rrn,n in\urumccrqicr unEnicynun,t rm
<br />[l cci'ly rh!, in rh.Frri rrun.colthc *n n{trhichrhisp!,rnir n issucd.l shru nor cq)loy any ll.^on inanynmtur
<br />$ 0sro b.mm \ubjdr ro rhc wor*.r' omp.n*rion laws otcrrlilornir, Md aBmc rtur irl should b.r.nr subjd h lnc
<br />workdC onD.nsarirn tmvisions ol Scrio. ll00 of rh. I ibi Codc. I shrll. fonhsirh onDly wilh ttbs pmvnions..
<br />$ARNINC: l-lilurc ro scurc work.r( c.n,pctrsuri{nr corcruec i\ unhwtuL and \hrll \ubFct ra.mrk,rtr b di'ninrll,-tulric\ ntrd
<br />cilil finc\ un lo onc hundrcd rhouslld dolhr (llOo.OG)). in oddirion lo lhc con or.ompcn\rrion. dnnrsc\ a\ pn'ridcd r(x rh.
<br />sNlion:1076olrhc bhor,Codc, in'.r.{ ond aunmy s fer .
<br />-",,o,iiiihC- :;,M.eI ucENsED(ox.raafl)B
<br />DLqA.EAIION
<br />I hcftby rmin und.r printry of p.rjury rh,r I m li.cnsed rtulcr pbvistun olChlpld 9(...mncin8 *nhsccthn 7Cr00) olDivkiofl -l
<br />o, rh! Bdsinc$and Proacsst,n\ C{dc. lnd nrliccnE h in lull lbrcea.{lctLcr.
<br />CONSIBIJEIII)NI.DNDIIG.AGENI:I
<br />I h.rcb, alfirm undcr FrulryofFdury rhln lhsr is 0 consrruction kndios a-rcfty for rhc p.rrorMce ofrhc *orl fo! which lhis pcrmil i
<br />nsucd (SN .109?. Civ C.).
<br />APIIICANLIECI.ABAIION
<br />I h.n6y airm und.r pcndlry of pcrjury on. or tnc following declelrions:
<br />Dcmlirion Pcrnih-Asbcaros Nori,icarion Fcdcol Rquldions (Till€ ts). Pd6)
<br />_R.quied L,ns of Notfra'nrn
<br />-l
<br />ccd if, rhd lhc icdcml r.Blhtn r Eg..din8 NsiEsros rcmvd arc mr npplic0bL ro lhG pmFr.
<br />[4!f'1i4, rh r harc Eod rhh applic.rion and srorc rfiIr rhe ft,vc intonnsxotr n conccr I a8re ro omprt wirh .ll ciry and c.uory
<br />ordinanccs and Stotc Llws Ebtiry ro b!ildinB cotrsrdcrion. and hcrcby ouhori^ rc!rcscnrorilcs ofrhk Cn, and Counry lo cmd !p{nrhc
<br />rl$!c trrnrioncd l)n)p.dy ft, inspc.lion purpo$
<br />Applicntrr or lll.Dr siaml ure
<br />n"-,r* -**,rnr,. \a,lor\tQ \I *,\46€L ^,, oLlotltg
<br />Site-Work
<br />Underground
<br />Pole Bases
<br />Light Standards
<br />S pas, Pool, Fountarns
<br />Signs (monument)
<br />Lite Salet y /Low Voltage
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />To rquerng
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rough)
<br />Ceilinqs (Hard & Soffit Rouoh
<br />Ceilings (T-Bar Rough)
<br />Ivleter Release
<br />Rough Q,/tQ/rh,'Vr^-6> \
<br />Service It/eler U-
<br />FINAL tb/// rB (orn6A
<br />Notes, Remarks, Etc v
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